Reconstruction Using Your Own

Tissue (Autologous)

Many tissues from the body can be used to rebuild the breast after mastectomy. The best spot to get the tissue from depends on your body type. The lower abdomen is the first choice for most women at it provides the needed fat and skin while placing the scar in a spot that is less visible. It also provides a cosmetic tummy tuck that is appreciated by most woman.

Both the DIEP and SIEA flaps use abdominal skin and fat from the lower part of the abdomen. The difference between the two is the choice of blood vessels that nourish the flap tissue.

In the DIEP flap, only the skin and fat tissue are taken from the donor site. The muscle itself is not used and therefore this procedure is significantly less invasive than earlier methods of breast reconstruction.

The blood vessels of the SIEA flap are more superficial, and therefore, less dissection is required than in the DIEP flap. The decision as to which flap is performed is based on whether or not a patient has these vessels, which is not know until the surgery is underway.

Once the abdominal tissue is safely detached from the abdomen it is re-attached to the small blood vessels in the breast area, resulting in a microsurgical tissue transfer. A small piece of cartilage on the third rib is removed to allow access to the blood vessels on your chest that the abdominal flap will be connected to. The tiny blood vessels are connected together using microsurgery techniques. Once this is complete, the blood flow to the tissue is restored. Next, the tissue is shaped to fit the mastectomy defect.

Due to the complex nature of the surgery, the procedure can be lengthy – often close to four hours for one breast, however the effort are rewarded by excellent cosmetic results. The procedure is much less invasive then earlier techniques, so recovery is faster. The operation leaves a horizontal scar on the lower abdomen, similar to that created in a cosmetic tummy tuck, resulting in a slimmer abdominal contour that is appreciated by most women.

In patients where there is not enough abdominal fat and skin, a second choice for breast reconstruction is the upper inner thigh region. This is a new technique where an elliptical piece of skin and fat is taken from the upper inner thigh. The incision is closed as if the patient was having a thigh lift. A small muscle (the gracilis muscle) is taken with the flap in most cases, however there is no functional loss from removing this muscle.
Once the tissue is safely detached from the inner thigh it is re-attached to the small blood vessels in the breast area, resulting in a microsurgical tissue transfer. The tiny blood vessels are connected together using microsurgery techniques. Once this is complete, the blood flow to the tissue is restored. Next, the tissue is shaped to fit the mastectomy defect.

For patient where the abdominal or thigh do not provide sufficient tissue, the gluteal region or buttock can also be used. Both the IGAP and SGAP procedures use tissue from the gluteal region or buttock. The difference between the two is the choice of blood vessels that nourish the flap tissue. SGAP is the preferred procedure of choice because the scar is lower - approximate 1” above the gluteal fold but it may not be available to all patients.

The scar on the buttock and the need for a symmetry operation on the opposite buttock reduces its appeal, and requires a longer operation. It also has a slightly higher failure rate.

Once the tissue is safely detached from the buttock it is re-attached to the small blood vessels in the breast area, resulting in a microsurgical tissue transfer. The tiny blood vessels are connected together using microsurgery techniques. Once this is complete, the blood flow to the tissue is restored. Next, the tissue is shaped to fit the mastectomy defect.

Implant Reconstruction

Implant reconstruction uses a temporary expander to stretch the skin and muscle. Approximately three to six months after the placement and expansion of the expander a permanent implant replaces the expander to give the final breast mound shape.

The permanent implant is a silicone bag filled with saline (salt water) or gelled silicon. All permanent implant shells are made of silicon. In other words, both saline and silicone implants have a silicon shell – the only difference is what is inside the shell. Saline implants are filled with salt water (saline) and silicone implants are filled with gelled silicone.

An important consideration to the use of an implant is that the implant is truly not “permanent”. Implants have a life expectancy of between 10 to 20 years, and most are replaced between 10 to 15 years.

There are four main steps of implant reconstruction:

Step One: Expander Placement
The expander is a silicone bag placed below the pectoralis major muscle of the chest at the time of the mastectomy. The expander bag is partially inflated. The procedure is completed by closing the mastectomy defect, and a drain is left under the remaining breast skin.

Step Two: Filling ExpanderApproximately two weeks after the placement of the expander, the expander is inflated by placing a needle into the filling port and injecting saline solution. This is done weekly until the expander is 20% larger than the breast on the other side. Some pain and discomfort similar to that of a pulled muscle is felt for a day after each expansion.

Step Three: WaitingOnce the required volume has been reached, the expander is left in place for three months. This allows time for the overlying muscle and skin to stretch. The breast with the expander will look larger and will feel much harder than the opposite breast. You can expect some level of discomfort during this time period.

Step Four: ExchangeThe next operation is done three to six months later. At this time, the expander is taken out and replaced with a permanent implant – either silicone or saline, whichever is decided on at this time. The final implant is placed below the pectoralis muscle in the “pocket” that was created by the expander in the previous months.

Step Five: Nipple ReconstructionFinal adjustments and nipple reconstruction are done six to eight weeks after the placement of the implant. Nipple reconstruction is done under local anesthesia and only takes 30-45 minutes to complete. The areola is done by tattooing to make the colour of a nature areola. Each tattoo can take one hour and may need to be done one or two times to achieve the right colour;

Potential Complications with Implant and Expanders

Immediate (less than 1 week)

Infection

Extrusion- the implant is forced out of position

Hematoma- blood collection under the skin

Seroma- serum fluid collecting

These complications occur in 1 to 10% of patients and are treated with antibiotics or a minor repeat operation.

Short-term (1 week to 3 months):

Infection

Asymmetry of reconstructed breast when compared to other breast

Extrusion

Capsular contraction- formation of scar tissue around the implant

Leakage, or rupture.

These complications may require a surgery to be corrected.

Long-term:

Capsular contraction

Leakage, rupture,

Infection

Asymmetry of reconstructed breast when compared to other breast

These complications call for a re-operation in 30% of patients within four years of the initial breast implant reconstruction surgery.

Check out the video at winnipegwomen.net of Dr. Ed Buchel in the Operating Room demonstrating some of the surgical and patient monitoring equipment purchased by Keeping Abreast.